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“We signed 4 DNR orders this month and you’re telling me you did CPR on her?” by Monica Williams-Murphy, MD

Dr. Monica Williams-Murphy is a Board Certified Emergency Medicine Physician, who practices in one of the largest emergency departments in the United States at Huntsville Hospital. Through her writing and speaking, she is devoted to transforming the end of life into a time of peace, closure and healing. Media Page

QUESTION: How can a little, frail 82 year old lady with advanced dementia have this written in her chart:

And this order at her nursing home:

But come into the emergency department after she has died with this drilled into her upper left arm:

And this tube sticking out of her throat (with frothy blood shooting out of it):

And this automated CPR device crushing her frail chest wall? When her healthcare orders were for the opposite- to allow her to have a natural death with comfort and dignity surrounded by her family.

(And trust me it looks more pleasant and desirable on this dummy than when it is caving in the chest of a little granny)

This type of clear, portable document would have ensured that this little lady’s wishes were respected everywhere: home, hospital, nursing home, during EMS transport, etc.

A POLST– type order would have prevented her son-in-law from having to say to me, “We signed 4 different DNR orders this month and you’re telling me you did CPR on her?”

~~~~~~~~~~~~~~~

(This is a true account. This little granny was “coded” for 30 minutes total. Only after she arrived to the emergency department and I pronounced her dead was I able to find a DNR order written in the fine print of the paperwork from the nursing home. The nurse caring for her back in the nursing home did not know the order was there, the paramedics did not know the order was there, and I did not know the order was there until we had done everything to her that she did not want done. My entire staff, the paramedics and the family were upset that we had disrespected her wishes. If you do not want this to happen to yourself or someone that you love, contact your local physicians and legislators to support provisions for the POLST to be available and used in your state and region. A POLST is a bright, standardized form that is signed once (not “four different times”) which directs all subsequent healthcare providers on your healthcare wishes. Knowing, respecting and honoring a person’s wishes at the end of life should be the “standard of care,” or at the very least, a standard of decency.)

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Thank you for another awakening post. Because I’m not on the front lines, there’s something I don’t understand, so I’ll ask.

Is there any time in the process of an event like this where providers can (ought to) pause and ask whether there’s a DNR order, or whether one is desired *now*; instead of just acting in just this one way? Or is there a choice — do you have to keep this up to the ridiculous end?

Or, could have the time in error at least been reduced by checking with family, in awareness that it is reasonable to think that this woman did not want all of that? Thank you for sharing your point of view on this.

I agree this is horrific and happens too often, but help me understand how the POLST form would have prevented this – would not the SNF staff need to know about it (like the DNR order) How would the paramedics find it when called in an emergency? What makes it more immediately accessible than the orange card and hospice note? Often those forms are on the front of a chart. Thanks for all input as our state also considers POLST.

So sad. I was with my husband and able to speak on his behalf and knew he trusted me to honor his wishes. We must all have this conversation with our partners and constantly revisit the subject with all those involved in their care. I am a Canadian.

Putting the POLST in a picture frame and hanging it in a prominent place would be a good idea too. Of course having copies in the files of the decision making individuals teams would be a good idea.too.

It’s one of the things to do to reduce the regret-grief issues around loss journeys.

No matter how brightly coloured and universally accepted a form is, it is still another piece of paper that must be correctly filed and attached to notes, then read in depth when required. Patients in hospitals and care facilities here are fitted with a non-detachable wristband showing their name and, if applicable, admission number. A second red-coloured wristband bearing the patient’s name and the signature of the authorising person creates a readily recognisable DNR notification for all healthcare professionals encountering that patient, without ever wasting time looking for/at the patient’s notes.

O M G.
These stories make me nauseous, even after decades of practice.
I believe there are still only 26 states with POST ( Physician orders for Scope of Treatment) or POLST forms.
In my search in early 2013 I interviewed in Michigan and found out that the state had stopped the effort to put a POLST in place. I could not fathom doing HPM work there without this order. When I left my native VA, there was an order that is a “durable DNR” but not a POLST. Here in OR, POLSTs are used a lot, but many are still unsure they should sign one, even in Hospice care, and some skeptical that it will be followed. Families are often fearful of them.

We need to continue to talk to legislators, medical Boards, and high profile people who can speak up!

ALSO- tell your families, your doctors, and clergy that you have wishes that are to be respected- this especially includes grandchildren, who may not have enough life experience to know why it’s important. Write your wishes down, even in non POLST states, and copy them to the hospitals, which often keep digital copies.
keep the conversations going.
Thank you.

Lissie, I was thinking of something similar – seriously. Flash drives are so tiny these days. Why not wear one around the neck, like a necklace. Make it a habit to wear it all the time. The flash drive can then contain ALL the directives we want and need. And it would be constantly available to all health care personnel! It would be “tattooed on the chest,” so to speak… An alternative to national acceptance of the POLST, till we have that firmly in place. — ??What do you think of that??

Heartbreaking! Working to get POLST in Florida but I do agree that this could still happen. It seems there was a huge breakdown in very important communication between medical staff in her facility and when she was transferred. Isn’t the DNR on bright yellow paper and why wasn’t that communicated during report at each shift change. Hopefully a lesson was learned here by all involved and protocols and processes changed so it never happens again. Again, this is heartbreaking –

With Extended Care Professionals’ eMAR and Resident Face Sheets you can post DNR orders right on your residents home screen and face sheet. Contact me today for a demonstration to make sure this does not happen in your community.

The fragmented communication surrounding end of life care often results in horrific deaths like this. A POLST effort will help in honoring a patient’s or family’s wishes about death with dignity. Thanks for sharing this post. Hopefully, it will begin to filter down to the grassroots level where the impetus for political change can occur.

I wanted to share my story… As a Nurse Practitioner in Palliative Medicine, we all have our own issue with getting the DNR and how people in general even after education are scared of not being treated for anything…We educate and educate that it does not mean DO NOT TREAT but..

I was watching a show called the AFFAIR on Showtime and in the episode the mother and daughter are talking about signing the DNR and the daughter who is the health care proxy and a nurse states to her mother do you realize that if we sign the DNR that she will die that they wont do anything even if she chokes on a “grape”…

If you can try to DVR this episode sorry I was unable to foward it it was aired Dec 7

As a paramedic these calls are amongst the most distressing to attend. I am under a legal obligation to begin CPR If no DNR is present. If I do not I will be charged with negligence, lose my license, lose my job and quite probably face a civil suit. I MUST SEE a DNR signed by the patient, his doctor, and his lawyer. (this particular criteria applies to the jurisdiction where I work, your area may have different laws) I can not take the family’s, nurse’s, doctor’s, or anyone else’s word for it. Let me assure you one of the very first questions asked on a call like this is “Where is the DNR?” The displeasure I feel having to perform a full code on someone who did not want it is immeasurable. Fortunately, in the area where I work patients are regularly given a ‘level of care’ form that accompanies all of their paper work. This works well for patients that live in nursing facilities but it is not generally completed with those people still living in their home. I must emphasize the importance of having this paperwork completed prior to requiring Emergency Services. It can be a difficult discussion to have but it is far more difficult having to watching a loved one endure full resuscitation efforts when a person knows it was not the patient’s wishes.

Let me also add it is easy to speak about this issue when it remains a discussion. When it is your loved one lying on the floor not breathing, regardless of how prepared for the moment you think you are, you won’t be. A signed DNR is no protection from the raw emotion a person goes through as a loved one dies. I have been begged, threatened, pleaded with, to please do something; when all I can do is be a witness to the passing of another human being. It is a rare privilege to be invited in to such a private moment and I believe most Health Care Workers do their best to honour it with the dignity it deserves.

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